Constipation in the elderly by alicejenny


									Postgrad. med. J. (September 1968) 44, 728-732.

                                         Constipation in the elderly
                                              E. GORDON WILKINS
                                    Consultant Geriatrician to the York Hospitals

Causes                                                         While considering lack of essentials one should
   Most of the causes of constipation in younger            mention lack of thyroid: constipation is usual in
age groups apply to the elderly and I will not              hypothyroidism which is easily missed, as a harsh
attempt a systematic classification (Table 1). When         voice, dry skin, cold intolerance and slow mental-
bowels have not acted for some days after illness           ity may all be attributed to old age.
relatives will say 'But she hasn't eaten anything'-            Muscular weakness is often found in the
and they are right. Lack of food whether from               elderly. The diaphragm is weak, hiatus hernia
starvation or illness may be a cause, especially            common, and chest and heart conditions may
if food is easily absorbed and lacking in insoluble         further make straining difficult. Weak abdominal
cellulose residues or roughage. Lack of sufficient          muscles, wiAth hernia at various sites often ignored
fluids may also cause constipation. This may be             by patient and physician, all add to the difficulty.
due to sweat loss in fever or hot weather, loss             It is possible that the bowel musculature itself
by vomiting, or diuresis for instance in diabetes,          gradually weakens with age.
causing dehydration. A helpless old person can                 Bowel abnormalities such as carcinoma or
easily become dehydrated even with ample fluid              diverticulitis should be considered.
on the locker, simply because nursing staff do                 Rectal stasis or dyschezia. Neglect of the
not ensure that it is taken. Even if given fre-             normal call to stool sent up to the brain when
quently, much is often spilt and little swallowed.          the rectum fills may be due to a variety of
Sometimes the elderly, who have small capacity              reasons.
bladders and suffer frequency of micturition,                  The elderly do not rush off to school or office
habitually take insufficient fluid for fear of incon-       but there may be aversion to the discomfort of
tinence or the need to make frequent visits to              the toilet. This may involve a difficult journey,
the toilet. With old kidneys passing urine of               climbing stairs with laboured breathing or arth-
fixed low concentration the risk of dehydration             ritic joints, or negotiating in winter the icy steps
is the greater.                                             and slippery yard to the cold outside closet. It
                         TABLE 1                            is surprising how many old people endure such
         Some causes of constipation in the elderly         conditions in old housing which would not be
                                                            tolerated by the young. Fear of pain from piles
Lack of physiological needsFood                             or fissure may add to the aversion.
                           Cellulose residues                  Depression is usually associated with constipa-
                           Thyroid                          tion, but I think probably the commonest cause
Muscular weakness, herniae Diaphragm                        in the elderly of neglect of the call of the full
                           Abdominal wall                   rectum is the brain dulled and damaged by
                           Pelvic floor                     cerebral vascular disease. The bowel soon
                           Bv ,vel musculature              becomes lethargic and overloaded and the patient
Bowel abnormalities        Carcinoma                        ceases to be aware.
Neglect of call to stool   Discomfort of toilet
                                                               Many drugs cause constipation. Paradoxically
                           Fear of pain-piles, fissure      the first to be considered are purgatives. Bowel
                           Vascular brain damage            obsession is common as the older generation were
                           Depression                       indoctrinated with the need for 'cleansing the
Drugs                      Purgatives                       system'. The laxatives they often take may empty
                           Iron                             the whole colon instead of only the distal portion.
                           Antacids-calcium carbonate       Physiological constipation ensues while the colon
                           Anti-spasmodics                  refills, which in turn is regarded as a need for
                           Anti-hypertensives               more pills. Indeed many symptoms formerly at-
                           Anti-Parkinsonism drugs          tributed to constipation are now known to be due
                           Barbiturates, sedatives
                                                            to the purgatives taken.
                                            Constipation in the elderly                                    729
   Among iatrogenic causes must be remembered              in finding. She died of bronchopneumonia and
iron, compound codeine tablets, antacids such as           post mortem showed no growth anywhere.
calcium carbonate and aluminium hydroxide,                    (2) Constipation may be associated with mental
antispasmodics such as propantheline, anti-                confusion and restlessness in the old person. The
hypertensive drugs and ganglion blockers, drugs            chronic discomfort of constipation may make
for Parkinsonism such as benzhexol or benztro-             her confused but unable to identify the cause,
pine, and barbiturate sedatives, which for other           just as a baby will cry when uncomfortable from
reasons also are best avoided in the elderly.              a wet nappy or projecting pin without being
                                                           able to say what is wrong. Alternatively it may
Syndromes                                                  be that confusion from say a minor stroke will
  Though constipation may occur in isolation or            prevent the brain responding to the call to stool
in combination with a great variety of symptoms            and so initiate constipation. Which comes first
certain syndromes (Table 2) occur sufficiently             does not matter provided the association is recog-
commonly in the elderly to justify mention.                nized: improvement of mental function usually
                                                           accompanies the treatment of constipation.
                        TABLE 2                               Mrs L.H. aged 88 had been forgetful for some
      Some syndromes of constipation in the elderly        months, disturbed and noisy at nights, but able
                                                           to walk and dress until a week before admission
     1. Anorexia, weight loss, lassitude-? growth          when she took to bed with nausea but no vomit-
     2. Mental symptoms                                    ing. Since then she had become more confused,
           Confusion, restlessness                         repeatedly getting in and out of bed, and had
     3. Urinary symptoms                                   fallen on the stairs, causing bruising but no bone
           Frequency, incontinence                         injury. On admission she was confused and rest-
           Infection                                       less, climbing over the cot sides. There was no
           Retention with overflow                         significant finding except a doubtful plantar res-
     4. Spurious diarrhoea, faecal incontinence            ponse, but she was very constipated. This was
     5. Intestinal obstruction                             treated during the next few weeks and her mental
                                                           state gradually improved, though there were
                                                           relapses, one being associated with a chest infec-
   (1) The patient presents with anorexia, weight          tion. However she eventually became able to
loss and lassitude, symptoms which give rise to            walk, dress and attend to her own toilet, and for
the suspicion of a growth. Barium meal will ex-            the last 4 months has lived a normal social life
clude carcinoma of the stomach. Barium enema               in our convalescent hospital, helping other patients
is often unsatisfactory as ordinary preparation            by doing little jobs for them. Her niece, remem-
fails to clear the loaded bowel, but if this even-         bering her former confusion and restlessness,
tually excludes colon pathology the incidental             refused to have her back so she has now to
correction of constipation may result in improve-          await a place in a Welfare Home.
ment. However, this does not always happen.                   (3) Constipation may present entirely with
   Mrs K.C. aged 70 gave a history of a stroke             urinary symptoms. There may be frequency of
15 months before with two more recent recur-               micturition, incontinence and urinary infection
rences and she had been bedfast at home for 6              for which antibiotic treatment will fail unless the
weeks. I was called to see her for an attack of            constipation is also treated. Or there may be
vomiting with constipation for a week and in-              retention with overflow dribbling incontinence,
continence. She was admitted with a view to re-            commonly due to faecal impaction.
habilitation and regulation of bowels. She                    (4) Spurious diarrhoea from faecal impaction
improved for a time and was able partially to              is well known in geriatrics but the inexperienced
dress herself and walk with a frame. However               nurse is often misled. It is reported that the
her appetite was poor and she persistently lost            patient is dirty and constantly soiling with faeces.
weight. Chest X-ray showed nothing significant             When I feel the faecal masses I insist on the
and barium meal was also negative. Constipation            nurse also putting on a glove and feeling them,
remained as shown by palpable scybala in colon             and she marvels to find the patient constipated
and rectum. This was treated with some success,            with liquid faeces escaping around the irritating
but her general condition continued to deterior-           scybala. Sometimes a single faecal mass forms a
ate. Nortryptiline was given as she was thought            ball-valve obstruction which a patient of mine
to be depressed. She lost over 20 lb (9 kg) in             diagnosed herself. She was a very interesting case.
weight in 2 months and we thought she must have               Mrs MS. aged 83, living alone, was admitted
a growth somewhere which we had not succeeded              one cold January day with accidental hypo-
730                                                            E. Gordon Wilkins
thermia and a temperature of 87°F. She gradu-                               and gave a history of anorexia, weakness and
ally improved but when a month later she was                                constipation similar to the first syndrome des-
almost ready to return home she suddenly                                    cribed earlier. Six weeks before admission she
developed acute rheumatoid arthritis of hands                               had a fall and went to her daughter's where she
with anaemia, raised ESR and strongly positive                              continued weak and ill with vomiting and diar-
latex test. As this subsided she was depressed and                          rhoea. On admission she was dehydrated and
preoccupied with her bowels, complaining that                               emaciated with anaemia, skin pigmentation, glos-
something came down and caused a stoppage.                                  sitis and angular stomatitis. There were no clinical
How right she was, for a ball-valve of solid                                signs of carcinoma. The bladder was full and the
faeces was doing just that! I broke it up and                               rectum plugged with a mass of solid faeces, so
evacuated it, but a fortnight later Sister had to                           the diarrhoea had been spurious. She was given
do the same again and in spite of treatment,                                fluids, complan, iron and vitamins and the bowels
twice more in the next month. She became more                               were treated with Senokot by mouth and Dulco-
anaemic in spite of iron, occult blood tests were                           lax suppositories. After temporary improvement
positive and a barium enema then showed an                                  she gradually deteriorated to her death. Unfor-
annular carcinoma of the descending colon just                              tunately permission for post mortem was refused.
distal to the splenic flexure. This was removed                                I postulate that when living alone she began
by Mr Matheson with end-to-end anastomosis.                                 to get constipated, her appetite declined and she
A saccular aneurysm of the abdominal aorta,                                 did not get herself proper meals. Her daughter
noted clinically, was confirmed at operation. She                           said that in all the 6 weeks she was with her
did well and went for convalescence but there                               she did not have her bowels moved properly,
had a stroke with left hemiplegia. She made re-                             merely passing small quantities of liquid motion.
markable recoveries from this and a recurrence                              Further anorexia and vomiting perpetuated a
6 weeks later, but succumbed 2 months after                                 vicious circle of malnutrition.
that to bronchopneumonia. Post mortem showed                                   Similarly on the mental side confusion, cerebral
the colon cancer completely cured but the path-                             vascular disease or depression may lead to neglect
ologist added 'there is evidence of constipation'.                          of the call to stool and constipation. Chronic
Let us not imagine constipation is easily treated!                          discomfort from this may aggravate the confu-
   (5) Finally there are the cases sent in as acute                         sion, or pain from the fissure or piles may cause
intestinal obstruction, and sometimes even opened                           fear, and both may lead to further neglect of
up by the surgeon.                                                          going to the toilet. Or there may be a crossover,
                                                                            as in the first case described (Mrs K.C.), arterio-
Vicious circles                                                             sclerotic dementia and depression causing con-
   From the foregoing it may be seen that vicious                           stipation leading to anorexia and weight loss with
circles (Fig. 1) may be set up both on the physical                         suspicion of growth.
and mental side. Physically any debilitating ill-
ness may render the old person weak and often                               Treatment
bedfast and constipated. Appetite is lost, resulting                           The advantages of getting the elderly patient
in further wasting, malnutrition and weakness. I                            up, out of bed and active are many, but not
think this occurred in the following case:                                  least among them is management of the bowels
   Mrs H.A.S. aged 85 had been living alone                                 (Table 3). It is essential for the toilet to be near,
                                                                            warm, comfortable, of suitable height, and with
             Physical                           Mental                      hand grips. Unlike younger age groups the
             Illness                     Vascular brain damage              elderly are not usually short of time.
       Confinement to bed                     Depression

               Weakness                 Neglect ot cal to stool                                      TABLE 3
                                                                                     Management of constipation in the elderly
                                                                            The toilet   Nearness, warmth, comfort, height, hand-grips
Malnutrition                   with                       Confusion, fear   Diet         Fruit, vegetables, fluids
                              loaded                                        By mouth   Lubricants
                              rectum.                                                  Bulk producers
                                                                                       Stool softeners
               Anorex ia     Overf low        Discomfaor
                                                                                       Laxative drugs
                                with       pain (fissure, piles)            Per rectum Digital examination
                              spurious                                                 Suppositories
                                                                                       Small enemas
 FIG. 1. Vicious circles of constipation in the elderly.                               (Large enemas)
                                      Constipation in the elderly                                    731
   The importance of diet was brought home to         duced. However, I am afraid the practice of giv-
me   by a paraplegic patient of mine.                 ing them intermittently in purgative doses still
   Miss E.H. is now aged 62 and has been              goes on.
paralysed and anaesthetic from the groins down           Of all the agents used from below I would put
for 30 years from a pathology never established       first the exploring finger. There are well known
at the time, but there was a previous history of      aphorisms stressing the importance of the rectal
tuberculosis. Fortunately for her the sacral nerves   examination. The presence of faeces in the
supplying bladder and rectum escaped so she           rectum of a patient unaware of the fact is diag-
retained control. She was, however, very constip-     nostic of constipation, and the consistence-
ated, with bowels that could only be persuaded        whether hard or soft-gives us further informa-
to act with difficulty with regular aperients. She    tion. Digital evacuation of a loaded rectum results
developed a resistant anaemia which was found         in surprise, relief and gratitude from patient and
to be due to chronic renal disease. Blood urea in     relatives, but this is only a beginning. Nursing
June 1966 mounted to 480 mg and she was put           staff who traditionally preside over the patient's
on treatment which included a Giovanetti diet         bowels should be taught the technique of painless
containing much fruit and vegetable. From then        rectal examination-pressing backwards with the
on bowels acted daily and were no problem.            flat of the well lubricated finger before inserting
Latestest blood urea incidentally is 38 mg but        the tip inwards-so that progress of treatment
anaemia persists.                                     can be regularly checked. I recently discovered
   Specific measures divide themselves into those     faecal retention with overflow in a patient in one
given from above and those from below. There          of my wards. In spite of my instructions treat-
are various categories of substances given by         ment was not given daily and progress was not
mouth. Of lubricanta liquid paraffin is typical,      checked. I found the condition unchanged a fort-
but disadvantages of long-term usage are well         night later and had to do a digital evacuation.
known; lymphatic blockage, interference with             Enemas are not used routinely in our wards. The
absorption of fats and fat-soluble vitamins, and      small Fletcher's enema has its advocates, and
the discomfort of anal seepage.                       some use warm olive oil or glycerine. In general
   Bulk producers whether from Psyllium seeds         they have been, replaced by suppositories and
or Sterculia, such as Normacol, or cellulose          we prefer the bisacodyl (Dulcolax) suppository.
derivatives such as methyl cellulose (Celevac) or     Staff should be instructed not to push it into
hydroxyethyl cellulose (Prepacol) have their uses     the faecal mass but to insert it in contact with
in colostomy management or preparation for X-         the rectal mucosa so that absorption can take
rays, but when the aged bowel has already             place. Some like a glycerine suppository, or a
become insensitive the further bulk seems only        moistened Beogex suppository which produces
to add to faecal distension. However they have a      carbon dioxide with explosive effect.
place in treatment.                                      Our routine is either Senokot, Dulcolax or
   Stool softeners or wetting agents are useful in    Dorbanex at night followed by a Dulcolax sup-
breaking up faecal masses in chronic constipa-        pository in the morning until regularity is
tion. Dioctyl sodium sulphosuccinate is the agent     achieved, attention being paid, of course, to diet
in Dioctyl Medo and Norval, poloxalkol in             and fluids.
Dorbanex. These are usefully combined with the           I would stress in conclusion that the treatment
anthracene laxative danthrone in Normax and           of established constipation in the elderly requires
Dorbanex. The former is only in capsules but if       a course of daily treatment and is not just a
these are found difficult to swallow liquid           matter of an occasional aperient or enema from
Dorbanex is useful.                                   the District Nurse. With faecal incontinence it
   I will not attempt to describe all the various     is worth much effort to make the patient socially
drugs that have been used to treat constipation.      acceptable again by re-educating the bowel to
Gone are the days of castor oil or rounds with        function at convenient times. It may take weeks
large bottles of black and white mixtures. The        rather than days of regular treatment and super-
only two laxatives we use in our Geriatric Unit       vision and even then one may not be successful
are Senokot, the well known standardized senna        as the following case shows:
preparation, and bisacodyl (Dulcolax). Both are          Mrs L.K. a woman of 82 had taken to bed a
thought to act after absorbtion by stimulation of     month before admission complaining of pain in
Auerbach's plexus in the large intestine, and         the back and legs and inability to stand. She was
both are useful. They are best given regularly        cared for by an 89-year-old husband who found
daily, the dose being gradually increased until the   it difficult to help her to the commode. She was
desired effect is obtained and then gradually re-     thin, weak and anaemic with low blood pressure
732                                       E. Gordon Wilkins
and oedema of the feet. Faecal masses were felt      large mass of presumed faeces in the descending
per abdomen and per rectum and there was a           colon with a distended bladder needing a catheter,
sacral pressure sore. Haemoglobin was 90 g the       and a rectum overflowing with spurious diar-
blood film showing both macrocytosis and iron        rhoea. Several attempts were made at digital
deficiency change. There were no neurological        evacuation and Dulcolax suppositories were con-
signs of sub-acute combined degeneration.            tinued. She lingered on in a pathetic state and
Lumbar X-ray showed osteoporosis and osteo-          died 6 weeks after admission. Post mortem
arthiritis. She was given Neo-Cytamen 1000 ,ug       showed as expected widespread bronchopneu-
daily for 5 days, Fersemal, Senokot at nights and
Dulcolax suppositories in the mornings. Though       monia. The upper alimentary tract was normal.
there was a reticulocyte response of 12% the         The descending and sigmoid colon and rectum
haemoglobin went down to 80g and she devel-          were enormously dilated by impacted faeces, the
oped a chest infection treated first with a course   total mass like a rugby football measuring 12x
of tetracycline. When sputum grew penicillin         9f in (30 x 24 cm). There was no organic cause
sensitive Staph. pyogenes she was given penicil-     of obstruction. Pressure of the faecal mass had
lin. Meanwhile her general condition deteriorated    caused bilateral hydronephrosis. Our treatment
and her pressure sore was worse. There was a         of constipation had to admit defeat!

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